Bayshire Torrey Pines Post-acute
BAYSHIRE TORREY PINES POST-ACUTE in SAN DIEGO, CA — inspection on February 21, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
for s/s of infection, notify MD of any changes. every day shift for wound care .
- Skin & Wound Evaluation 2/4/25: Coccyx Present on admission.
Measurements area: 1.2 cm length 1.9 cm width 0.9 cm.stage 3 pressure injury to sacrococcyx [tailbone and the triangular shaped bone to the lower spine] . 2/7/25 at 2:10 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 3 ' s admission skin assessment dated [DATE] indicated, .Coccyx [tailbone] with small skin opening and quarter sized redness but was checked marked as a pressure ulcer. LN 1 stated the pressure ulcer care plan was initiated on 1/26/25 and should have been initiated within 48 hours (three days after admission). LN 1 stated it was important that the pressure ulcer care plan was in place within 48 hours to prevent delayed care and treatment for the pressure ulcer. LN 1 further stated delayed care can contribute to the worsening of pressure ulcers and infections if not cared for timely.
On 2/7/25 at 2:38 P.M., an interview and record review was conducted with the Minimum Data Set (MDS) nurse.
The MDS nurse stated Resident 3 ' s admission skin assessment dated [DATE] indicated Resident 3 had a pressure ulcer to the coccyx.
The MDS nurse stated it was important that the pressure ulcer care plan was completed within 48 hours to provide a baseline description for the monitoring the pressure ulcer ' s status with interventions and/or worsening of the pressure ulcer and infection.
On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON).
The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer.
The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed.
The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments.
A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .
555746 02/21/2025
Bayshire Torrey Pines Post-Acute 13101 Hartfield Ave San Diego, CA 92130
cleanser, pat dry and apply santyl [ointment that removes dead tissue] f/b [followed by] DSD
(MDS) nurse.
The MDS nurse stated the admission assessment states open area to coccyx with measurements. I believe that ' s a pressure ulcer.
The reason why is because they [admission nurses] are told to not stage it until the RN wound nurse is able to stage it if there is really a pressure ulcer.
The MDS nurse stated that the pressure ulcer care plan as not in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing.
On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON).
The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer.
The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed.
The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments.
A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .
Findings
1. A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked).
A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1. 5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care.
A clinical chart review for Resident 1 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25.
- Admission Medical Doctor (MD) ordered on 2/1/25 indicated, .Treatment: Sacralcoccyxgeal [tailbone and the triangular shaped bone to the lower spine] open wound.
Apply Barrier Cream To Area To Protect Skin For Maint [maintenance] Tx [treatment] x14 Days BID [twice daily] &PRN [as needed] every day and evening shift for (Skin Integrity Prevention) for 14 Days .
555746
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555746 B.
Wing 02/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshire Torrey Pines Post-Acute 13101 Hartfield Ave San Diego, CA 92130
Findings
1. A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked).
A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1. 5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care.
A clinical chart review for Resident 1 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555746
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555746 B.
Wing 02/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshire Torrey Pines Post-Acute 13101 Hartfield Ave San Diego, CA 92130
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.